Monday, March 7, 2016

Like two rivers merging to flourish the earth, the Spinning Babies 2016 World Confluence joins birth and bodyworkers to address the increasing rates of fetal positioning challenges.
This conference brings top names in birth and bodywork together with rising stars whom you may not have heard of yet.

Wednesday, September 21, we'll invite our international and other long distance travelers to attend a Spinning Babies Workshop. There will be a local Spinning Babies Workshop in Minneapolis/St.Paul, MN and one in Eau Claire, Wisconsin (2.5 hour drive to the SW of St. Paul, MN) this Spring and Summer for regional birth workers. See the calendar for more US and international workshops. Attending this workshop will only make the conference that much more comprehensible and raise the value of your learning. (7 continue education credits or CEUs. Registration will appear at the end of February, you will want to register fast!)

Thursday, September 22nd offers pre-conference workshops (with 5 or 7 continuing education credits per 5 or 7 hour workshop). See the details for Thursday pre-conferences with Carol Phillips, DC; Phyllis Klaus, on Hypnosis and other BodyMind approaches to complications of pregnancy particularly premature labor and hyperemesis gravidarum - a great preparation to understand how to work with women, including hypnosis for women with breech babies which she covers on Friday afternoon); Angelina Martinez Miranda, Mexican Midwife; Adrienne Caldwell, MT; Jenny Blyth and Fionna Hallinan, Australia's Birthwork trainers; Sarah Longacre, Prenatal Yoga Instructor Trainer, on integrating Daily Essentials into your yoga studio offerings - she'll get you moving!; and myself on Belly Mapping for pregnant parents for a 2 hour presentation which includes painting a few bellies (no CEUs).

Friday, September 23rd is "Interest Track" day, with quality presentations on current birth and bodywork topics:

Penny Simkin gives 4 presentations with her excellent presentations which are worth gold to providers and birth activists alike. Professionals and educators across the birth spectrum find her quality presentations changing practice and approach. The world of birth workers have praise for Penny on their lips at every given minute around the world.

The first baby I (unexpectedly) caught was my friend's breech baby girl. So it's a natural for me to have a day on breech for providers. I've invited Jane Evans and Anke Reitter because these two give a concrete and practical understanding of how the baby moves through the pelvis o,r gets stuck - and unstuck! In this track, I present a new conference learning technique I call, since so many of us are birthies, "Precipitous Presentations" which are 18 minute presentations on a single important point from a speaker's topic. Friday, Adrienne Caldwell does a single technique for turning a breech, Phyllis Klaus presents on Mindbody for turning a breech and Angelina Martinez Miranda talks about the beauty of breech birth from a traditional Mexican perspective. Take notice! Angelina will be teaching on traditional midwifery practices for pregnancy on Thursday! A panel with Obstetrician Dennis Hartung, Midwife Nicole Morales, and parents of breech babies brings us back from lunch. Anke Reitter, Jane Evans, and I will go into detail with providers about breech birth complications and the practical solutions of rotation and flexion to save lives.

Jenny Blyth and Fiona Hallinan are the Birthwork duo from Australia that can't be missed! Follow them to San Francisco after the conference where they'll give their complete workshop for 3-days on the pelvis, pelvic floor, and more. It's experiential and movement based. And a lot of fun!

Sunday, March 6, 2016

I've been talking about maternal positions in general and the previous blog post gives you basic knowledge. This post talks about water birth and breech.

For the safe breech water birth you need to have uterine moment and an open pelvis.
Cornelia Enning, German Midwife, solved that by having the mother standing in a rain barrel. Literally a rain barrel. That is quite different than a typical water birth tub.

When a woman gives birth in a regular birth tub she is:

Less likely to rock fully back and forth bringing the baby's arms through the curve of carus, the curve of the pelvis

Unable to put her chest to the floor which opens the brim when women are on their knees

Less likely to raise their buttocks to protect their baby from taking a breath of air only to be dipped back under water

This picture of a recent breech birth "in air" shows the baby in the ideal direction for the arms to be born. The baby's spine is towards the mother's front. The mother's kneeling position encourages this position. Her rocking encourages muscle relaxation and the little movement helps baby descend.
This baby's right elbow has just been born. Baby's toes are curled showing good tone. The cord is actively circulating blood and the baby is an active particpant in bringing the arms and head out.
Muscle movements in the baby's abdomen (seen more easily with mother on her knees) show the baby flexing to bring down the larger parts of her own body.

This baby has floated into the oblique diameter after the birth of the arms. Is the head oblique, too? The mother is curled over her knees, shutting her pelvis down a little bit. This baby required help to get the head out. See the mother's deep crease compared to the above picture of the full perineum?

This is a clue that the head is not flexed. The lack of maternal movement in the tub or length of descent in any breech birth - even before the umbilical cord is seen - can reduce oxygen when the placenta may begin to separate. Don't wait when you see a deep crease. Go get your baby.

Open the diameters of the inlet by putting chest to floor... oh, oops, you can't dunk the mother to do this. So she can open her pelvis by:

Raising her bottom by pushing up on the top of her feet - starting to straighten her legs

Anterior pelvic tilt (increase the curve shape of the lower back by pushing the buttocks out)

Standing and anterior pelvic tilt

Get out of the tub (Seems dangerous to baby's neck! Seek chiropractor for atlas adjustment.)

Kneel on the floor and put chest on the floor

and in both cases Midwife does one of the following to flex the head:

Frank's nudge (touch subclavical nerve under the collar bone, between shoulder and ribs in the dip. This is the 2009 version as explained by Adrienne Caldwell in 2012. I like this version because it uses physiology rather than force.)

Lift the baby's chest to the perineum (towards baby's chin) and then slide baby forward to mom's belly

Finger forceps the perietal bones to tuck the chin. Do this by rotating the top of the head with your finger tips on either (or one) side. This is like making baby nod "yes" and the chin will tuck.

Then the midwife can use fundal pressure to bring baby out if the mother can't push the baby out.

Remember the head is in the vagina and not every uterus will push out the baby's head by the time involution is well under way, though of course, by far, most will. When you need baby out to help start breathing and heart beating, you can do Kristeller's maneuver which is simply push down on the TOP of the uterus. This is not suprapubic pressure as in shoulder dystocia. You get on the top of the uterus and give a tap or a mighty push, depending on which is necessary. How hard you press depends on whether the pelvic floor is that of your average pelvic floor or of an athlete.

Baby's head must be flexed and facing mom's anus, not her hip, to fit out the bottom pelvic level.

Breech birth is a clever adaptation of the baby when the baby doesn't have room to be head down in the pelvis. Balance the ligaments, fascia and muscles to allow baby head down. Some breechings stay breech because of uterine shape (bicornate or other shape), anterior placenta, low thyroid function, or physical anomaly. I believe it is more often a twist in the pelvis, sacrum, or cervical ligament causing the breech position. A second twin or a triplet may just be matching available space and can flip head down once their sibling is born or with a little help from maternal positioning with gravity or the provider's skill, if necessary.

Because I mention some things about breech here, doesn't mean this is the whole story of all you need to know to help a breech or that I am not mindful of the skills needed. I simply want to address one issue of the breech and water birth in the "horizontal" birth tub.

We can't compare Cornelia Enning's breech water birth outcomes with other tubs. Mothers stand up in her "vertical" tub and she has them put one foot on a stool. She gets into the tub if the baby needs help (Midwifery Today, Oct. 2013; Sao Paulo, Brazil SiaParto, June 2015; Midwifery Today, Bad Wildbad, Germany, Oct. 2015) Her pool water is typically cooler than American custom, as well.

My supposition is that standing with a foot on a stool opens the pelvic diameters while allowing mother to move instinctively. Babies might still get stuck, but not because of the mother kneeling over her knees.

Now the midwife can touch the self-progressing breechling.
Mom has lowered her shoulders to the bed and opened her pelvic diameters to release her baby.
Photo by Indigo Birth Photographer, Allie Parfenov.

In a horizontal tub, sitting upright on a stool may be better for birthing a breech. But the two times I've helped in that position the babies needed help, one for an arm and one because the placenta separated before the birth was complete. But in hands and knees water birth I've found issues due to maternal position.

Now midwives will say, "But, I've seen breech babies shoot out in the water." Yep, so it isn't all breeches. It's simply too many to ignore. A surprise breech will come fast most of the time without getting caught. That is one reason there wasn't time to transfer to the hospital or even discover baby was breech. Planning a breech birth puts the matter in to another category.

Learn the diameters of the pelvis so you know what maternal movements open which part of the pelvis. You can then suggest a subtle move that can save a life. You can also know how to rotate baby to free the stuck body part (arms or head in the breech) and figure out what to do more easily if the

baby is stuck in a way that is not in the books. That happens when baby is stuck inside the symphysis pubis, for instance, and baby can be lifted and rotated or the arm brought back into the pelvis.

Ok, I've exhausted this post. Learn more about breech at the Spinning Babies 2016 World Confluence, Sept. 23rd on the Interest Track day's breech session. Dr. Anke Reitter and Midwife Jane Evans will be sharing the skills they've spent their lifetimes perfecting.

Much has been written about maternal positioning in labor. Some of it validates and some of it seems to contradict what we have been recommending. I'd like to offer a look at maternal positions for pregnancy and labor from a "3 Levels" perspective.

In pregnancy, the assumption seems to be that positioning mothers with gravity is enough to reposition the baby also. Providers don't expect an immediate change. However, common questions arise by those who haven't rejected the Optimal Foetal Positioning approach, "How long does a fetal re-position take?" or "Which position will rotate a posterior baby or flip a breech?"

In labor, maternal positions are chosen for comfort by mothers and are suggested for progress and comfort by providers.

In Pregnancy use alignment in your posture to allow better function of the muscles.
This means sitting on the front of your sitz bones and not lounging back on the sacrum in a semi sitting position very often. Sitting up makes the belly a hammock, as Midwife Jean Sutton describes in Optimal Foetal Positioning.

Spinning Babies adds muscle balance to allow room for baby to settle spine to front in the anterior position. We understand that when gravity alone doesn't bring baby head down, and then over to mother's left side, then there may be a reason relating to the uterus having enough room to let baby slide into place. Sometimes that is a placenta or a unique shape to the uterus, like a septum in the upper uterus holding the head in place, - or a twin in the way! But more often it seems to be a bit of a twist or tightness in the ligaments, connective tissue or muscle. A lack of room might be because the mother's hip is rotated (twisted) enough to shorten a leg or pull the cervical ligaments over to one side, creating a fold or slight twist of the lower uterus.

The normal uterus often seems to lean to the right. The fundus, midway through pregnancy,
is often noted to be slightly higher on the right than the left. The right side is steeper and the left side more round.
Normal "right obliquity" of the uterus makes the uterus steeper on the right side. Baby's flexion
is likely to result from laying on the round side (usually left) and babies who are extended may be more likely to
come from the steep side (almost always the right side).
Balancing the muscles and ligaments and aligning the pelvis may support a good fetal flexion.

Movement in special ways to lengthen and "balance" the muscles helps make room for the baby.
Yoga in general is good. But yoga in and of itself may or may not balance the pelvic muscles. Whether or not the muscles that a particular mother needs help with is addressed in her yoga class depends on the full range of motion and style of yoga promoted by her class instructor. Daily Essentials download video is designed for that full range of motion that seems to help the majority of women using it from 20 or 30 weeks gestation.

Addressing ligaments and the fascia (connective tissue) helps address the levels of the pelvis - a fancy way of talking about baby's pathway in birth.
Above the pelvis is the respiratory diaphragm, broad ligament and round ligaments.
At the pelvic brim is the sacral promontory, they symphasis, and inguinal ligaments.
Deep in the pelvis are the pelvic floor, ishiocavernosis and performis (on the back side, but effecting sacral movement and the internal surface of the sacrum is deep. Ok, the analogy needs tolerance.

Use Balance, Gravity, and Movement to enhance pregnancy comfort and potentially ease childbirth.

Now in labor, open the inlet with the posterior pelvic tilt to make room for baby to drop down.

MRI of the Pelvic inlet with and without the line showing anterior-posterior diameter of the inlet.

Once baby is half way through, at or near the ischial spines, the peanut ball is a helper, or the diagonal lunge (stand and lunge towards the side while still facing forward).

Once the nurse can see baby's head, doing an anterior pelvic tilt opens the outlet. The lunge will help again. And the birth stool is brilliant! Make it a medium height birth stool so the mother isn't in too deep a squat for strength in pushing and have a squat when baby is almost crowning. Or a hip squeeze.

You can learn more about the levels of the pelvis with these three products

Insights for Labor tear-off sheets for educators and providers which gives parents a one-page handout, two-sided, to refer to during labor. Maternal positions are illustrated so they know what to do when, for comfort and labor progress. These cost shipping, and can't be mailed to Australia or South Africa, two countries where my products seem to disappear into customs. See Capers Bookstore in Australia to order your copy, Mate!

The Quick Reference Cards (not cards, actually, but a download) which I sometimes call the 3 Levels Cards, but they include brief instructions (reminders really, the full instructions and contraindications are on the Spinning Babies Website.

The video download, Spinning Babies, Parent class which goes into the balancing techniques and the tips for labor - in depth! The 3 levels of the pelvis are well explained. You will learn a lot even as a provider from this "birth geek parent" video. This can be ordered as a DVD, too.